Oronasal Fistula Research Articles

Tongue Flap for Closure of Complex Oronasal Fistula.

Complex oronasal fistula is one of the most frequent secondary complications of cleft palate correction and is considered a reconstructive challenge. Tongue flaps are one of the procedures for the treatment of complex fistulas associated or not with multiple previous procedures, offering a high success rate, few complications, and problems during its development. This study evaluates the efficacy in terms of functionality, esthetic, donor area morbidity and clarifies surgical technique steps. Descriptive cohort study was performed between August 2011 to August 2021 where an anteriorly based dorsal tongue flap was performed in 30 patients with complex palatal fistulas, evaluating outcomes in terms of technique reproducibility and flap viability, correction of oronasal regurgitation, speech, donor site morbidity, complications, and esthetics. The senior author has used this technique with consistent clinical outcomes to improve complex oronasal fistula with minimal complications, with a good success rate in terms of correction of the palatal defect with imperceptible alteration of the lingual donor area. In addition, establishes a specific definition of persistence and recurrence of oronasal fistula. The tongue flap is considered the gold standard in complex oronasal fistula reconstructions with satisfactory outcomes, and it offers an adequate amount of vascularized tissue achieving fistula closure without functional or esthetic impairment of the donor area and is a highly reproducible technique.

Huge Nasopalatine Duct Cyst Treated by Transnasal Endoscopic Marsupialization: A Case Report and Literature Review.

Nasopalatine duct cyst (NPDC) is the most common nonodontogenic cyst originating from the epithelial remnants of the incisive canal in the maxilla. NPDC is treated with complete enucleation via a sublabial or transpalatal approach, and recently tranasnasal endoscopic marsupialization has been gradually used. However, in large and extensive cases, it is difficult to remove the cyst completely, and there is a high risk of postoperative complications, including oronasal fistula. Therefore, tranasnasal endoscopic marsupialization is recommended as an effective treatment modality. Herein, we report a case of a 49-year-old man with a very large NPDC with a maximum diameter of 58 mm. NPDC was successfully managed by transnasal endoscopic marsupialization under general anesthesia without any major problems. No postoperative complications or recurrence occurred until 12 months postoperatively. Transnasal endoscopic marsupialization for large NPDC is minimally invasive and useful.

Chirurgische behandeling lip- en verhemeltespleet

Surgical treatment of cleft lip and palate Children with cleft lip and/or palate often undergo multiple surgical procedures to repair the lip and/or palate. The lip closure is usually done between the ages of 3 and 6 months, which may or may not be preceded by presurgical orthopedic treatment. The techniques used for cleft lip repair vary between different teams and surgeons. In addition to a correct alignment of the lip parts, the restoration of the continuity of the orbicularis oris muscle and the correct positioning of the base of the nostril are important. The timing and sequence of the hard and soft palate repair vary and are a trade-off between the beneficial effect of early palate repair on the velopharyngeal function and speech development, and the possible negative effect of palate repair on maxillary growth. The hard and soft palate can be closed simultaneously or in 2 operating times. Again, several techniques are available, always with the aim of achieving a complete closure of the mucosa without oronasal fistulas and with a functional velopharyngeal sphincter. For the latter, repositioning the palatine levators and restoring their continuity are crucial.

Addition of a Buccinator Musculomucosal Flap Improves Surgical Outcomes of Conventional two-Flap Palatoplasty: A Comparative Study.

The surgical outcomes of novel two-flap palatoplasty adding a buccinator musculomucosal flap were compared with those of conventional two-flap palatoplasty to clarify the effects of lengthening the nasal mucosa of the soft palate using a BMMF in cleft lip and palate or cleft palate cases. Retrospective, comparative study. Tertiary, cleft team. Non-syndromic patients undergoing primary cleft palate repair using two-flap palatoplasty with BMMF (BMMF group) or conventional two-flap palatoplasty (non-BMMF group). Palatoplasty between January 2012 and March 2020. Perceptual Japanese speech evaluation, rate of an indication for additional speech surgery (AS), rate of incidence of oronasal fistula (IF) including spontaneously closing fistula, and rate of occurrence of oronasal fistula (OF) present for more than 3 months. Of 92 analyzed patients, 70 received two-flap palatoplasty with BMMF and 22 received two-flap palatoplasty. In the BMMF and non-BMMF groups, the respective percentage of hypernasality (no, mild) was 91.4% and 77.2%, no nasal emission was 71.4% and 63.6%, velopharyngeal function (competent, borderline competent) was 83.7% and 77.4%, intelligibility (very good, good) was 93.7% and 86.4%, AS was 1.4% and 13.6%, IF was 7.1% and 36.4%, and OF was 1.4% and 9.1%. Significant improvements were observed for AS (p = 0.0412) and IF (p = 0.00195) in the BMMF group, with no recorded major adverse effects. Adding a BMMF on the nasal side of the soft palate to conventional two-flap palatoplasty significantly improved postoperative outcomes. This approach may therefore be a good option for cleft palate treatment.

Surgical techniques to reduce oronasal fistula risk in wide cleft palate repair: a systematic review

BACKGROUND Wide cleft palate is a common congenital anomaly, particularly in developing countries with limited access to plastic surgeons and specialized cleft centers. It can be severe and may contribute to the development of oronasal fistula, which can occur in up to 78% of cases. Despite numerous surgical techniques for wide cleft repair, the best method remains unclear. This study aimed to identify surgical techniques for wide cleft palate repair to minimize the occurrence of oronasal fistula.
 METHODS Literature searching was conducted using multiple online databases including PubMed, Scopus, and Cochrane Library. The keywords used were “cleft palate”, ” surgery”, “technique”, “palatoplasty”, and “wide”. Inclusion and exclusion criteria were applied to select relevant studies, and the quality was assessed.
 RESULTS A total of 12 studies discussed surgical techniques to repair the primary wide cleft palate and their outcome on oronasal fistula formation. The surgical techniques included modified Furlow palatoplasty, two-flap palatoplasty, and modified Bardach’s two-flap palatoplasty. The incidence of oronasal fistula was 9.6% (n = 28/291) in one-stage Furlow palatoplasty and 12.0% (n = 24/200) in the modified one-stage two-flap palatoplasty.
 CONCLUSIONS Two-flap palatoplasty and Furlow palatoplasty (and their modifications) were the safe surgical techniques for wide cleft repair with a low occurrence of oronasal fistula.

The Role of Platelet Rich Fibrin for Closure of Oronasal Fistula Post Palatoplasty through Abilities to Keep Growth Factor Activity for a Relatively Longer Period and Stimulate Tissue Regeneration Effectively

Oronasal fistula is one of the unfortunate consequences of cleft palate surgery. This can be done after palate surgery in patients with cleft palate, defined as an abnormal connection between the oral and nasal cavities. Multiple systems have attempted that classification. It can be a small, symptomatic or asymptomatic fistula that needs correction. Its speed varies greatly depending on many factors. Both surgical and non-surgical methods (the advantages and disadvantages of each should be considered) are available for correction, and there are combination therapies that help improve surgical outcomes. Platelet-rich fibrin (PRF) is a novel Generation platelet concentrate, very easy to prepare and handle without the use of biochemicals. Its production is dependent on the accumulation of platelets that release cytokines and growth factors. Enriched with growth factors, this hemostatic plug is easy to prepare and operate. Adapted for soft and hard tissue healing. It is used in various fields of dentistry, especially oral and maxillofacial surgery. Reports on the role of PRF in repairing oronasal fistula closure are sparse in the literature, especially in relation to other soft tissue flaps.

The Role of Platelet Rich Fibrin for Closure of Oronasal Fistula Post Palatoplasty through Abilities to Keep Growth Factor Activity for a Relatively Longer Period and Stimulate Tissue Regeneration Effectively

The Role of Platelet Rich Fibrin for Closure of Oronasal Fistula Post Palatoplasty through Abilities to Keep Growth Factor Activity for a Relatively Longer Period and Stimulate Tissue Regeneration Effectively

Free Flap Reconstruction of Recalcitrant Defects in Cleft Palate Patients.

Defects of the palate can be as a result of oronasal fistula of cleft patients and the ablative surgery of tumors. There are many studies about reconstruction of the defects of plate in the literature and most of them are related to tumor surgery. Despite the use of free flaps in cleft patients being not a new approach, the articles in the literature are very few. The authors describe the experience of oronasal fistula reconstructions with free flaps with a new modification of tensionless inset of the free flap's pedicle. Between 2019 and 2022, 2 males and 1 female, 3 consecutive cleft patients underwent free flap surgery because of recalcitrant palatal defects. One patient had 5 and each of remain had 3 unsuccessful reconstructive attempts previously. The age of patients was ranged from 20 to 23 years old. Radial forearm flap was the option of oral lining reconstruction for all patients. In 2 patients, the flap was modified as a skin tail was linked to the flap for covering the pedicle as tensionless closure. There was a mucosal swelling in first patient who underwent classical pedicle inset as mucosal tunneling. In 1 patient there was a spontaneous bleeding from the anterior side of the flap and it stopped without medical interventions, spontaneously. There was no additional complication. All flaps survived without anastomosis problems. Incision of the mucosa rather than tunneling provides good surgical exposure and bleeding control and modified flap design may be beneficial and reliable for tensionless pedicle inset and covering.

A Review of the Use of Buccal Fat Pad in Cleft Palate Repair.

To review the available evidence on the use of the Buccal Fat Pad in primary and secondary Cleft Palate repair. This is a narrative review. A computerized literature search was conducted for articles published till February 2022 using the Mesh phrases buccal fat pad AND cleft palate, Bichat's Fat pad AND cleft palate, buccal fat pad OR Bichats Fat pad AND cleft palate. A total of 35 articles were included in this review based on the set eligibility criteria. Most of the studies were retrospective case reviews (n = 16, 45.7%), and the aggregate number of patients from all included studies was 666. Reported uses of the buccal fat pad (BFP) in association with cleft palate repair include the closure of central cleft palate defect and nasal floor in primary cleft palate repair, oronasal fistula repair following primary repair of cleft palate, and closure of relieving incision defect in primary repair of cleft palate. Complications reported were 24 cases of Oronasal Fistula (ONF), 2 dehiscences, and 4 transient mucosal defects. The high success rate, vascularity, ease of tissue harvest, and low donor site morbidity all support its use as an adjunct flap in cleft palate repair, especially in the closure of wide palatal clefts, to prevent post-palatal repair fistula, wound contracture, and subsequently velopharyngeal insufficiency and possibly midface hypoplasia.

Unraveling a Major Burden of Orofacial Clefts Analyses: Classification of Cleft Palate Fistulas by Cleft Surgeons.

The objective of this study was to investigate how cleft surgeons classify palatal fistulas. We focused on three different anatomical locations (ie, hard palate, soft palate, junction hard/soft palate) to analyze agreement/disagreement at various anatomical locations. Cross-sectional survey study. Participants in an international webinar that focused on palatal fistula treatment were included. Participants were presented with a survey pre- and post-webinar. Frequency of used classification systems for classifying oronasal fistulas and the inter-rater reliability of the Pittsburgh classification system. A total of 141 participants completed the questionnaires prior to the webinar and 109 participants completed the survey after the webinar. In total, four classification systems were used (ie, Pittsburgh, Pakistan Comprehensive Fistula Classification [PCFC], anatomical and 'other'). The Pittsburgh classification was the most commonly used system in all cases. However, Pittsburgh inter-rater reliability was low (κ = 0.136 pre-webinar, and κ = 0.174 post-webinar). Surprisingly, a substantial shift was observed from the anatomical to Pittsburgh classification after the webinar, indicating increased awareness of the usability of the Pittsburgh classification system. This study demonstrates a large heterogeneity with regards to the classification of cleft palate fistulas. Interestingly, a shift was observed from the anatomical to Pittsburgh classification after the webinar. However, the inter-rater reliability for using the Pittsburgh classification was low. Classifying palatal fistulas in a homogenous fashion could enhance comparison of primary palate repair and could improve treatment of palatal fistulas.

Cocaine-induced granulomatosis with polyangiitis-an under-recognized condition.

Cocaine and cocaine mixed with levamisole are increasingly used in the UK and result in significant direct nasal damage in addition to promoting vasculitis. Our aims were as follows: (1) to identify the main symptoms and presentation of cocaine-induced vasculitis; (2) to provide evidence regarding the best practice for the investigation and diagnosis of cocaine-induced vasculitis; and (3) to analyse the clinical outcomes of patients in order to understand the optimal management for the condition. We performed a retrospective case series analysis of patients presenting with cocaine-induced midline destructive lesions or vasculitis compatible with granulomatosis with polyangiitis (GPA) from two large tertiary vasculitis clinics between 2016 and 2021. Forty-two patients (29 Birmingham, 13 London) with cocaine-induced midline lesions or systemic disease were identified. The median age was 41 years (range 23-66 years). Current cocaine use was common, and 20 of 23 samples provided were positive when routine urine toxicology was performed; 9 patients who denied ever using cocaine were identified as using cocaine based on urine toxicology analysis, and 11 who stated they were ex-users still tested positive. There was a high incidence of septal perforation (75%) and oronasal fistula (15%). Systemic manifestations were less common (27%), and only one patient had acute kidney injury. Fifty-six per cent of our patients were PR3-ANCA positive, with none testing positive for MPO-ANCA. Symptom remission required cocaine discontinuation even when immunosuppression was administered. Patients with destructive nasal lesions, especially young patients, should have urine toxicology performed for cocaine before diagnosing GPA and considering immunosuppressive therapy. The ANCA pattern is not specific for cocaine-induced midline destructive lesions. Treatment should be focused on cocaine cessation and conservative management in the first instance in the absence of organ-threatening disease.

Oronasal fistula repair with Combined Endoscopic & Transoral Approach (3 layer): Case report & Review of Literature

Oronasal fistula repair with Combined Endoscopic & Transoral Approach (3 layer): Case report & Review of Literature

The Early Operative Burden for Children Born with Cleft lip and Palate.

to audit the surgical management of infants born with non-syndromic cleft lip and palate (CLP) at an Australian cleft unit in a large tertiary paediatric hospital. Retrospective cohort study. A tertiary Cleft centre. 193 infants born with non-syndromic CLP were referred to the centre and underwent primary repair of their CLP between 2009 and 2020.Main Outcome Measures: (1) The timing and surgical repairs performed; (2) the frequency of postoperative complications; (3) the frequency of secondary Cleft surgery; and (4) the total Cleft-related operations performed for infants born with CLP. Four different surgical repair techniques were performed by six surgeons, and postoperative complications were uncommon (n = 14). Rates of oronasal fistula surgery (10.5% at five years of age; 14.3% at eight years of age) and velopharyngeal insufficiency surgery (8.7% at five years of age; 14.3% at eight years of age) were not significantly different across the surgical repair groups (p-value >0.05) and were comparable to international Cleft centres. Children underwent an average of four operative procedures in this audit period, including primary Cleft repair, ear, nose and throat surgery, and dental care. Surgery for managing Eustachian tube dysfunction was the most common surgical intervention following primary Cleft repair. Children born with non-syndromic CLP have a high early operative burden, with outcomes similar across the spectrum of techniques and surgeons.

Buccal transposition flap for closure of maxillary lip defects in 5 dogs.

To describe the technique and outcomes of the closure of maxillary lip defects using a buccal transposition flap and to identify potential routes of vascular supply to the flap. Five dogs treated clinically and 1 cadaveric dog head. Short case series and cadaveric study. A left maxillary labial defect and a buccal transposition flap were created on a cadaver head. Iodinated contrast was injected into the left common carotid artery and computed tomography was performed to assess the vascular supply. Medical records were reviewed for all dogs that underwent tumor excision with maxillary lip resection, reconstructed with a buccal transposition flap. The buccal transposition flap was perfused by branches of the angularis oris artery and superior labial artery. Five dogs were included in this study. All flaps survived. Three dogs developed postoperative complications, including oronasal fistula (n=2) and partial flap dehiscence (n=1). The cosmetic and functional outcomes were considered satisfactory in all cases. Buccal transposition flaps for the closure of large maxillary lip defects provided adequate functional and cosmetic outcomes. The buccal transposition flap had vascular contributions from the angularis oris artery and the superior labial artery.

Nasal Septal Flaps for Repair of Large or Recurrent Palatal Fistula: Report of Technique and 4-Year Experience.

Large or multiply recurrent oronasal fistulas following cleft palate repair present a challenging problem. Nasal septal mucoperichondrial flaps have been widely used for repair of skull base defects; however, their use in the repair of oronasal cleft palate fistulas has not previously been described. In this pilot study, the authors describe anterior palatal fistula repair using a nasal septal flap and review their experience with this technique over 4 years. Fourteen patients with anterior palatal fistulas not amenable to repair using local palatal flaps were included for analysis. The mean size of the fistula was 12 mm in maximum dimension. Flap healing with complete or near-complete closure of fistula was achieved in 13 patients (93%). Five of these patients had a small, slit-like residual fistula that was asymptomatic. Nasal septal flaps are a new technique for repair of large or recurrent palatal fistulas. The procedure is well-tolerated with minimal side effects, high success rate, and low incidence of recurrence. Therapeutic, IV.

Obturator Manufacturing for Oronasal Fistula after Cleft Palate Repair: A Review from Handicraft to the Application of Digital Techniques.

An oronasal fistula (ONF) is an abnormal structure between the oral and nasal cavities, which is a common complication of cleft palate repair due to the failure of wound healing. When some patients with ONF are unsuitable for secondary surgical repair, the obturator treatment becomes a potential method. The objectives of the obturator treatment should be summarized as filling the ONF comfortably and cosmetically restoring the dentition with partial function. The anatomy of patients with cleft palate is complex, which may lead to a more complex structure of the ONF. Thus, the manufacturing process of the obturator for these patients is more difficult. For performing the design and fabrication process rapidly and precisely, digital techniques can help, but limitations still exist. In this review, literature searches were conducted through Medline via PubMed, Wiley Online Library, Science Direct, and Web of Science, and 122 articles were selected. The purpose of this review was to introduce the development of the obturator for treating patients with ONF after cleft palate repair, from the initial achievement of the obstruction of the ONF to later problems such as fixation, velopharyngeal insufficiency, and infection, as well as the application of digital technologies in obturator manufacturing.

Methods of plastic surgery of the alveolar process in children with congenital cleft lip and palate

Alveolar cleft is a tornado-shaped bone defect in the maxillary arch. The treatment goals for alveolar cleft are stabilization and provision of bone continuity to the maxillary arch, permitting support for tooth eruption, eliminating oronasal fistulas, providing an improved esthetic result, and improving speech. Treatment protocols vary in terms of the operative time, surgical techniques, and graft materials. Early approaches including boneless bone grafting (gingivoperiosteoplasty) and primary bone graft fell into disfavor because they impaired facial growth, and they remain controversial. Secondary bone graft (SBG) is not the most perfect method, but long-term follow-up has shown that the graft is absorbed to a lesser extent, does not impede facial growth, and supports other teeth. Accordingly, SBG in the mixed dentition phase (6–11 years) has become the preferred method of treatment. The most commonly used graft material is cancellous bone from the iliac crest. Recently, many researchers have investigated the use of allogeneic bone, artificial bone, and recombinant human bone morphogenetic protein, along with growth factors because of their ability to decrease donor-site morbidity. Further investigations of bone substitutes and additives will continue to be needed to increase their effectiveness and to reduce complications.

Treatment of Adenoid Cystic Carcinoma of the Palate and Reconstruction of Defect With Nasoseptal Flap: A Clinical Case and Review of Literature.

Adenoid cystic carcinoma (ACC) is a malignant tumor arising from the salivary glands. While surgery is the mainstay of treatment for ACC of the palate, adjuvant radiotherapy and/or chemotherapy should be considered in high-risk cases. Oronasal fistula, a complication of palatal surgery, may cause speech disturbance and food regurgitation; the nasoseptal flap is a potential option to repair this defect as it is readily available and reliable. Here, we present a case of locally advanced ACC of the palate in a patient who underwent endoscopic-assisted transoral tumor excision with nasoseptal flap reconstruction postoperative chemoradiotherapy.

Otomicroscopic and functional outcomes after cleft palate repair via Sommerlad intravelar veloplasty vs. modified Veau-Wardill-Kilner push-back.

We aim to compare the modified Veau-Wardill-Kilner push-back technique (VWK) and the Sommerlad intravelar veloplasty (Sommerlad IVVP) in terms of middle ear outcomes and oronasal fistulae frequency in three years old children. For this retrospective cohort study, data were collected and anonymized from consecutive patients with cleft palate (with or without cleft lip) who underwent surgery in our hospital between January 2008 and December 2018. Patients with syndromic diagnoses and patients who underwent surgical treatment elsewhere were excluded. We collected data from 101 children (202 ears) regarding middle ear complications at the age of three, including acute otitis media, middle ear effusion, tympanic membrane retraction, tympanic membrane perforation, tympanic membrane atelectasis and chronic otitis media with cholesteatoma. In addition, the presence of oronasal fistulae and the number of ventilation tubes received by the age of three were recorded. The odds of children having a normal middle ear evaluation were 3.07 (95% Confidence interval (95%CI): [1.52, 6.12]; p<0.05) times higher when children received Sommerlad IVVP compared to modified VWK. With 40.7% compared to 26.7%, a significantly higher incidence of middle ear effusion was present in the modified VWK group compared to Sommerlad IVVP (X2(1)=4.38, p<0.05). Furthermore, this group needed significantly more ventilation tube reinsertions (X2(2)=12.22, p<0.05) and was found to have a significantly higher incidence of oronasal fistula (53.5% vs. 17.2%, X2(1)=14.75, p<0.05). The latter was significantly associated with a higher need for ventilation tube reinsertion (X2(1)=7.34, p<0.05). This study shows superior middle ear outcomes and fewer oronasal fistulae after Sommerlad IVVP compared to modified Veau-Wardill-Kilner push-back at the age of three.

Early Cleft Palate Repair by a Modified Technique Without Relaxing Incisions.

This study sought to evaluate a modified palatoplasty technique (MPT) concerning the postoperative outcomes and associated influencing factors. A retrospective cohort study. One hundred forty-three consecutive patients with non-syndromic cleft palate, who received MPT before one year of age within an oral and maxillofacial surgery department of a university-affiliated tertiary hospital between 2011-2017, were reviewed. The postoperative wound healing and velopharyngeal function (VPF) were the primary outcome measures. The sex, age at surgery, cleft type, cleft width, palatal width, soft palate length, pharyngeal cavity depth, and operation duration were preselected as influencing factors. Univariate and multivariate analyses were conducted. The mean age at surgery was 9 ± 1.31 months (5-11), and the average cleft width was 9.03 ± 2.41 mm (4-15). The rate of incomplete cleft palate was 84.6% while the complete cleft palate was 15.4%. Complete wound healing was reported in 96.5% while the others (3.5%) had persistent oronasal fistula. About 90.2% of cases have shown normal velopharyngeal function whereas the others (9.8%) had sustained velopharyngeal insufficiency. The wound healing appeared to be significantly impacted by cleft width and pharyngeal cavity depth (P = .015 and 0.049, respectively). However, none of the factors had a significant association with VPF. The present modified palatoplasty technique has obtained a low fistula rate and appropriate speech outcome. Therefore, this MPT could be promoted for early repairing cleft palate of different severities.